Quiz, book, and ATI questions

b. Empty nest

Which of the following is an example of of a patient experiencing a maturational crisis? a. academic failure b. empty nest c. job loss d. kidnapping

b. "I have more control over my thoughts and behaviors."

A client has obsessive-compulsive disorder (OCD). Which statement made by the client to the nurse would be the best indicator of improvement? a. "My friends don't know about my disorder." b. "I have more control over my thoughts and behaviors." c. "I only do my ritual to reward myself when I have been good." d. "I know that my thoughts and behaviors are not normal."

c. Identify the student's immediate concerns and feelings.

A 15-year-old female student visits the school nurse's office asking about date rape and pregnancy. She confides that her boyfriend forced her to have sex against her will. What would be the most appropriate initial intervention by the nurse? a. Teach methods of birth control. b. Teach safe sex practices. c. Identify the student's immediate concerns and feelings. c. Administer a pregnancy test.

c. Recent use of alcohol or other depressants

Before a newly admitted anxious client begins treatment with benzodiazepines, it is most important for the nurse to make which client assessment? a. Level of motivation for treatment b. Situational and social support c. Recent use of alcohol or other depressants d. Stressors and use of coping mechanisms

c. "I have a list of people that I can call if I need to."

Five days ago, a client was admitted to the hospital with major depression and suicidal ideations. The suicidal ideations are absent now and the client is preparing for discharge. Which client statement made to the nurse about going home demonstrates that an important outcome/evaluation measure has been met? a. "I'll finally be able to get some sleep." b. "I'll cook for myself." c. "I have a list of people that I can call if I need to." d. "I'll be able to take care of my plants again."

b. Generalized anxiety disorder

For the last year, a college student continually worries about finances, the weather, grades, and relationships. This is associated with which of the following diagnoses? a. Acute Stress Disorder b. Generalized anxiety disorder c. Panic disorder d. reactive attachment disorder

c. Each suicidal attempt should be taken seriously.

For the third time within a month, a client with borderline personality disorder took a handful of pills, called 911, and was admitted to the emergency department. The nurse overhears an unlicensed staff member say, "Here she comes again. If she was serious about committing suicide, she'd have done it by now." The nurse determines there is a need to teach the staff member which of the following? a. Clients with personality disorders rarely have completed suicides. b. The nurse should prepare the client for direct inpatient admission. c. Each suicidal attempt should be taken seriously. d. Exploration of suicidal ideas and intent should be avoided.

a. Assist the nurse to help the client express grief fully.

It is important for the nurse to deal with personal feelings about adoption, grief, and loss prior to advising a mother who recently placed her newborn baby up for adoption. This self-awareness would do which of the following? a. Assist the nurse to help the client express grief fully. b. Prevent the nurse from sharing any personal feelings with the client. c. Prevent the nurse from being personally affected by the client's choice in adoption. d. Assist the nurse to avoid discussing unpleasant feelings with the client.

a. Open awareness

The terminally ill client and family are discussing plans for the client's funeral. The nurse recognizes this as an example of communication indicating which kind of awareness? a. Open awareness b. Closed awareness c. Denied awareness d. Mutual pretense

a. If a person makes a suicidal attempt and fails, the risk for future suicidal attempts is increased. b. Warning signs, even if indirect, are often present before a suicidal attempt.

The client has suicidal ideation with a vague plan for suicide. When teaching the family how to care for the person at home, what should the nurse emphasize? Select all that apply. a. If a person makes a suicidal attempt and fails, the risk for future suicidal attempts is increased. b. Warning signs, even if indirect, are often present before a suicidal attempt. c. When the client no longer talks about suicide, the risk of suicide has decreased. d. Family members are responsible for preventing future suicidal attempts. e. Suicide occurring within the family environment indicates family dysfunction.

b. "Grandfather and I are going for ice cream tomorrow." c. "Grandfather will be back to take me to the ball game next week."

The grandfather of a three-year-old client died two days ago. Based on an understanding of normal growth and development, the nurse should anticipate hearing the client make which type of comment? Select all that apply. a. "Grandfather would not have died if I had wished a little harder." b. "Grandfather and I are going for ice cream tomorrow." c. "Grandfather will be back to take me to the ball game next week." d. "Grandfather will be waiting for me when I die." e. "Grandfather is gone, and now I have to be strong and not cry."

b. Munchausen syndrome by proxy

The mother of a 6-year-old client in the emergency department (ED) says that the child vomits after every meal. The child has a normal appearance and is in no acute distress. This is the fifth time within 3 months that the child has been brought to the ED by the mother. The mother states, "This time I won't go away until my child is admitted for a complete and thorough workup. The doctors say there's nothing wrong, but I know my child is very ill." What should the nurse suspect about what the mother is experiencing? a. Panic level anxiety b. Munchausen syndrome by proxy c. Cluster A personality traits d. Dissociative identity disorder

c. The nurse should not touch a patient who is having a flashback.

Which is true about touching a patient who suffers from PTSD who is agitated while having a flashback? a. The nurse should touch the patient only after receiving permission. b. The nurse should touch the patient to increase feelings of security and safety. c. The nurse should not touch a patient who is having a flashback. d. The nurse should stand in front of the patient before touching.

b. A common expression of how men grieve loss and death

What is the nurse's most appropriate interpretation of a father who recently lost his eldest son to cancer who refuses to share his feelings in a support group and has not shown any tears related to the loss? a. The father's attempt to be strong for the rest of the family b. A common expression of how men grieve loss and death c. A dysfunctional expression of grief, and the client should be referred to counseling d. A common expression of denial and refusal to accept death or loss

d. It assists the nurse to help the parents express their grief fully.

What is the reason for nurses to have self-awareness when dealing with parents whose child has recently died? a. It prevents the nurse from sharing any personal feelings with the parents. b. It prevents the nurse from being personally affected by the loss. c. It assists the nurse to avoid discussing unpleasant feelings with the parents. d. It assists the nurse to help the parents express their grief fully.

b. Anniversary grief experience

What type of grief should the nurse suspect in a client who reports that since her husband's death four years ago, she has experienced migraine headaches and severe nausea each year around the date of her husband's death? a. Delayed grief b. Anniversary grief experience c. Disenfranchised grief d. Unresolved grief

a. Attend grief support groups. e. Accept professional assistance if needed.

What would be an appropriate outcome criterion for a client who has just lost a spouse through death? Select all that apply. a. Attend grief support groups. b. Stop expressing feelings about the spouse's death c. Avoid sharing loss with significant others. d. Plan a memorial tribute for the spouse. e. Accept professional assistance if needed.

d. Remain with the client.

What would be the best nursing action for the nurse to implement for a client who is having a panic attack? a. Ask the client to describe what was happening before the anxiety began. b. Teach the client to recognize signs of a panic attack. c. Instruct the client to remain alone until the symptoms subside. d. Remain with the client.

a. Allow the client to talk about personal memories of the mother.

What would be the most appropriate action by the community nurse for a client, who is crying and says, "My mother's funeral was yesterday. I'm so sad."? a. Allow the client to talk about personal memories of the mother. b. Explore the nature of the client's relationship with the mother. c. Ask the client to describe what led to the mother's death. d. Encourage the client to think about something other than the mother's death.

d. Are short, firm, and simple

When communicating with a client in a panic state, the nurse should ensure that statements made to the client have which characteristics? a. Are abstract and nonthreatening b. Are avoided until the anxiety disappears c. Are avoided until the client brings up the subject d. Are short, firm, and simple

d. "When children play in playgrounds, it makes me angry that my son will never be able to play like other children."

Which statement by the client would support the nursing concern of complicated grieving in a parent who is dealing with the death of her infant son 30 months ago? a. "I sometimes cry in my son's old bedroom because he's not there anymore." b. "I think of my son and I am sad that my new baby will never be able to know his brother." c. "I watch other toddlers in the neighborhood play, and I wish my son were still alive." d. "When children play in playgrounds, it makes me angry that my son will never be able to play like other children."

a. the patient has an unreasonable, severe fear of spiders

Which type of behavior indicates a patient is likely to be diagnosed with a specific phobia? a. The patient has an unreasonable, severe fear of spiders. b. The patient worries excessively about many things. c. The patient flips the light switch on and off 5 times before leaving a room. d. The patient complains of fear and intense physical discomfort with no known cause.

c. Anger

A 20-year-old client has just learned that both parents and two older siblings were killed in an automobile accident. The client is screaming "There is no God!!" while covering the ears and crying. The emergency department nurse should conclude these behaviors are consistent with which stage of the grieving process? a. Bargaining b. Denial c. Anger d. Depression

a. The client is experiencing feelings of hopelessness. b. A primary goal is to keep the client safe from harm. c. The client is experiencing a situational crisis. d. The technique of catharsis can facilitate healing in the client.

A 26-year-old client is admitted to the inpatient psychiatric unit due to suicidal ideation and a specific lethal plan for self-harm. The client states, "There's no reason to go on living. My best friend is dead, and I'm all alone now. We did everything together. Now I have no one to turn to or do things with." Which principles related to a crisis apply to this case? Select all that apply. a. The client is experiencing feelings of hopelessness. b. A primary goal is to keep the client safe from harm. c. The client is experiencing a situational crisis. d. The technique of catharsis can facilitate healing in the client. e. The client is experiencing a maturational crisis.

d. Withdrawal

A client who has refused to take the regular prescribed dose of clonazepam reports irritability, insomnia, tremors, and agitation. The nurse should conclude that the client is most likely experiencing symptoms associated with which of the following? a. Overdose b. Anxiety c. Manipulation d. Withdrawal

b. Voicing thoughts that are normal for children his age

A child, aged four, says, "If I can make a big enough wish, my daddy will not be dead anymore." The nurse should conclude that the child is doing which of the following? a. Expressing magical thinking common to much older children b. Voicing thoughts that are normal for children his age c. Delusional and should be evaluated by a psychiatrist d. Making up the story in order to avoid feeling sad and scared

c. Disenfranchised

A client arrives at a clinic in a very agitated state saying, "My life partner of 15 years has died of cancer and the family will not allow me to attend the funeral. They never accepted our relationship." The nurse should plan to facilitate the grieving process for this client because circumstances place the client at risk for which type of grief? a. Unresolved b. Inhibited c. Disenfranchised d. Delayed

c. Palpitations e. rapid heart rate

A client asks why a beta blocker medication has been prescribed for anxiety. When responding, the nurse should explain that this medication class is effective in treating which symptoms associated with anxiety? Select all that apply. a. Confusion b. Suicidal ideations c. Palpitations d. Insomnia e. Rapid heart rate

d. "Let's develop a safety plan for repeated violence."

A client comes to the emergency department with a broken wrist and severe bruises inflicted by a beating by the intimate partner. The client states an intention to remain in the relationship at this time. What is the most appropriate response by the nurse? a. "I will call a lawyer for you if you wish." b. "Here is a list of services that can help you." c. "You need to leave the relationship." d. "Let's develop a safety plan for repeated violence."

a. Identify support systems. c. Acknowledge personal strengths. e. Explore current life events that led to the suicide attempt.

A client has been treated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound. The client is now admitted to a psychiatric unit. The nurse schedules time to meet with the client on a one-to-one basis to discuss which client goals? Select all that apply. a. Identify support systems. b. Attend all social events if admitted. c. Acknowledge personal strengths. d. Discuss post-discharge living arrangements. e. Explore current life events that led to the suicide attempt.

a. A mood stabilizer c. A prn (as needed) anxiolytic d. An antipsychotic e. One-on-one observation

A client is admitted to the inpatient unit with a new diagnosis of bipolar disorder with a most recent episode of mania. The client's history indicates she recently experienced an unresolved crisis when her sister died from a heroin overdose three months ago. The client has been so busy raising her children by herself and working full time that she repressed feelings related to the event. The client currently manifests delusions, severe anxiety, and suicidal ideation. The nurse would anticipate which of the following will become part of her treatment plan? Select all that apply. a. A mood stabilizer b. A serotonin selective reuptake inhibitor (SSRI) c. A prn (as needed) anxiolytic d. An antipsychotic e. One-on-one observation

c. Discuss feelings of impending death and acknowledge the inevitable outcome. d. Explore what the person believes about the grieving process

A client is diagnosed with lung cancer and is expected to die within three months. What should the nurse assist the client to do at this time? Select all that apply. a. Avoid discussing the future or making future plans, as the future is uncertain. b. Allow caregivers to provide as much care as possible to reduce stress and to preserve energy. c. Discuss feelings of impending death and acknowledge the inevitable outcome. d. Explore what the person believes about the grieving process e. Verbalize need to avoid taking narcotic analgesics since they can cause clouded thinking.

d. Situational

A client presents in the mental health clinic saying, "I didn't expect it. They just told me this morning that I don't have a job any more. I can't think straight. I feel like I'm going crazy." The nurse should conclude that the client is experiencing which type of crisis? a. Maturational b. Adventitious c. Personal d. Situational

b. Allow the client to express feelings and perceptions about the incident.

A client seeks assistance at a crisis center. The client describes being intensely anxious and having nightmares since assisting with cleanup activities at a school where a student fatally shot a classmate. To assist the client to cope effectively, what should be the first action by the nurse? a. Send the client to the emergency department for further evaluation. b. Allow the client to express feelings and perceptions about the incident. c. Advise the client to avoid going near the school for at least six weeks. d. Arrange for the client to visit with a member of clergy.

c. Help the client to identify the problem and possible ways to manage it.

A client seeks help in a crisis clinic secondary to having several family members involved in a serious automobile accident. The client speaks in a loud, disorganized manner with frequent changes of subject. Which nursing approach is most likely to be effective? a. Arrange for one-time anxiolytic medication for the client. b. Assist the client locate the chapel or another quiet area. c. Help the client to identify the problem and possible ways to manage it. d. Encourage the client to identify family members involved in the accident.

d. Allow the client adequate time to carry out the ritual.

A client states, "I am always late for everything because I can't leave my room without checking every drawer and door to make sure they are locked. If I don't do that, I get so worried that I have to go back. I can't seem to stop my behavior." The nurse should take which action at this time? a. Remind the client that the staff will not allow others to enter the room. b. Explore childhood experiences that may have led to the behavior. c. Encourage the client to remain in the room until the urge to recheck has decreased. d. Allow the client adequate time to carry out the ritual.

b. The client continues to be at significant risk for suicide.

A client who admits to having frequent suicidal ideation is admitted to the psychiatric inpatient unit. During the assessment interview, the client says, "I really don't need to be here. I'm very much at peace with myself now." The nurse should make which interpretation about this client? a. The client has resolved suicidal feelings and is no longer at risk for self-harm. b. The client continues to be at significant risk for suicide. c. The client is ready to be discharged from the inpatient setting. d. The client has concluded that the risk for self-harm is no longer present.

b. Medications relieve symptoms but do not change the source of the anxiety.

A client who is receiving an anxiolytic medication is reluctant to participate in group therapy. The client states, "The pills I am taking will take care of my stress. I don't need to talk about my problems." What explanation should the nurse include in a response to the client's statement? a. The client will need to attend group therapy only until the medication becomes effective. b. Medications relieve symptoms but do not change the source of the anxiety. c. Many anxiolytics are habituating. d. The medications will not work unless the client participates in group therapy.

b. Actual c. Perceived

A client who underwent a gastric banding surgical procedure has a body mass index (BMI) of 24.8 and states, "I'm too fat. I always have been." The nurse concludes that this client has a disturbed body image related to which type(s) of psychological loss? Select all that apply. a. Permanent b. Actual c. Perceived d. Anticipatory e. Painful

a. Ideas of self-harm

A client whose life partner recently died from complications of AIDS has learned he has also converted to HIV-positive status. The attending healthcare provider's office referred the client to the crisis unit because the client "shut down" emotionally after receiving the lab results. Which is the nurse's priority concern in the initial assessment interview? a. Ideas of self-harm b. Available social support network c. Distorted thought processes d. Financial means to obtain medications

c. Dysfunctional grief

A client whose spouse died four months ago is admitted for inpatient psychiatric care. The client has been unable to work since the spouse's death and has lost 9 kg (20 lb). The client cries frequently and says, "No, I won't believe it. It's not true." The client further describes feeling "numb" and "empty." The admitting medical diagnosis is major depression. The nurse identifies which of the following as the priority concern? a. Disenfranchised grief b. Normal grief c. Dysfunctional grief d. Distorted grief

b. The client needs to be encouraged to verbalize feelings.

A client with generalized anxiety disorder states, "I now know the best thing for me to do is just to try to forget my worries." How should the nurse evaluate this statement? a. The client is developing insight. b. The client needs to be encouraged to verbalize feelings. c. The nurse-client relationship should be terminated. d. The client's coping skills are improving.

b. Hardiness c. Resilience d. Internal locus of control e. Appraisal of stressor

A female client presents to the crisis center as a victim of attempted rape earlier that day. She is initially distressed, but after venting her feelings with the nurse, states she will be able to overcome the incident. She says she feels she has control over her emotions and has had to deal with stressful events in the past. She states, "I've gone through other bad things in the past. I left my abusive husband five years ago; it motivated me to get my master's degree." The nurse should consider that which client characteristics will facilitate recovery from this event? Select all that apply. a. External locus of control b. Hardiness c. Resilience d. Internal locus of control e. Appraisal of stressor

b. The child is at current risk for developing depression and will remain so in the future.

A five-year-old child has been removed from the home because of sexual abuse by the stepfather. What information should the nurse include when teaching the child's mother about possible consequences the child might experience? a. Once an adult, the child should be counseled not to have children, as the child will become an abuser. b. The child is at current risk for developing depression and will remain so in the future. c. Because the abuser was someone well known by the child, the situation will be less traumatic for the child. d. Since the child was removed from the home at an early age, no long-term consequences are expected.

d. Report suspected sexual abuse to protective services.

A five-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The mother reports that she had left the little girl with her boyfriend the night before. Which action should be the nurse's first priority with this client? a. Teach the mother about symptoms of UTI. b. Obtain a urine sample to confirm a UTI. c. Assess the child for other health problems. d. Report suspected sexual abuse to protective services.

c. Caregiver stress related to overwhelming caregiving tasks and expectations

A frail 79-year-old female calls the home health nurse and says, "I am a failure, and I can no longer care adequately for my husband who has Alzheimer disease." She has been his primary caregiver for over five years; now he has become despondent, is unable to ambulate, and is difficult to manage. The nurse should determine that which priority nursing concern is most appropriate? a. Ineffective grief resolution related to not accepting personal limitations b. Inability to cope related to chronic illness c. Caregiver stress related to overwhelming caregiving tasks and expectations d. Isolation of the family related to altered state of health

d. Alarm

A healthcare provider has just told a client that surgery will be required to treat a health problem. After the healthcare provider leaves, the client reports feeling angry, tense, and shaky. The nurse notes that the client's palms are sweaty and the pupils are dilated. The nurse interprets this to mean that the client is experiencing symptoms consistent with which level of the general adaptation syndrome (GAS)? a. Resistance b. Exhaustion c. Generalized anxiety d. Alarm

c. Identify this situation as a medical emergency.

A mother brings in an eight-month-old infant who is having difficulty breathing. The nurse assesses bleeding in the baby's retinas. The mother states that the child was being cared for by the father while the mother was out of the house. What is the most appropriate initial response of the nurse? a. Inform the mother that the period of greatest danger has passed. b. A mother brings in an eight-month-old infant who is having difficulty breathing. The nurse assesses bleeding in the baby's retinas. The mother states that the child was being cared for by the father while the mother was out of the house. What is the most appropriate initial response of the nurse? c. Identify this situation as a medical emergency. d. Report the situation to the children's protective services agency.

a. "The underpinnings of social learning theory lay in the idea that violent behavior is related to the perpetrator's need for control and power." b. "Poor impulse control may be one reason for violent behavior."

A newly licensed nurse asks an experienced nurse about theories related to violent behaviors towards others. The experienced nurse should respond by making which statements? Select all that apply. a. "The underpinnings of social learning theory lay in the idea that violent behavior is related to the perpetrator's need for control and power." b. "Poor impulse control may be one reason for violent behavior." c. "Feminist theory states that it is due to the physiology of the male gender." d. "There is no etiologic basis for violent behavior towards others." e. "The male response theory states that women provoke men, and that women are responsible for the abuse."

c. do not leave the patient alone

A nurse is assessing a patient and discovers the patient is having suicidal thoughts with a clear and achievable plan. Which of the following interventions should the nurse initiate first? a. assign the patient to a private room b. document the patient's behaviors every 30 minutes c. do not leave the patient alone d. encourage the patient to sign a contract for safety

a. "If you are educated and have money, abuse does not happen."

A nurse is teaching a class on domestic violence to high school students. Which statement by a student would indicate to the nurse that further teaching is needed? a. "If you are educated and have money, abuse does not happen." b. "Violence often begins in a dating relationship." c. "The abuser will often apologize and promise to stop." d. "Abusers are often excessively jealous and possessive."

c. An attempt to relieve anxiety

A nurse observes a patient who has OCD repeatedly applying, removing, and then reapplying her makeup. The nurse identifies that the repetitive behavior in a patient who suffers from OCD is due to which of the following? a. An adverse side effect of anxiety medication b. Fear of rejection by staff and peers c. An attempt to relieve anxiety d. Acute Stress Disorder

a. Stay with the patient and offer reassurance of safety..

A patient is experiencing a severe panic attack. Which nursing intervention meets the patient's most immediate need? a. Stay with the patient and offer reassurance of safety. b. Teach deep breathing & relaxation techniques. c. Use clear, simple words and give the patient an educational pamphlet on anxiety. d. Administer anxiety medication.

c. Lethality of the method and availability of means

A patient says, "I plan on killing myself when I go home." Which of the following should be the nurse's priority assessment? a. Patient's insight into the reasons behind this decision b. Quality and availability of patient's support systems c. Lethality of the method and availability of means d. Patient's economic and educational level

c. Risks of pregnancy complications caused by abuse

A pregnant female comes to the emergency department with bruises on her arms and abdomen after a fight with her boyfriend. What is most important for the nurse to address when teaching this client? a. Assertiveness training to deal with the boyfriend b. Childbirth classes to prepare for the birth c. Risks of pregnancy complications caused by abuse d. Instructions on the use of resources available to her

a. "I understand that you do not like this, but I must be able to see you at all times to make sure you are safe."

A suicidal client is placed on one-to-one observation. When the nurse accompanies the client to the bathroom, the client loudly shouts, "I'm sick of being followed around and treated like a child who can't be trusted." What would be the best response by the nurse? a. "I understand that you do not like this, but I must be able to see you at all times to make sure you are safe." b. "Being angry and uncooperative won't change anything. I can't leave a suicidal client alone." c. "You don't have to be so loud. I do trust you, but I can't change the rules for you." d. "Since this is upsetting to you, leave the door open and I'll wait outside it for you."

c. Mutual pretense

A terminally ill 78-year-old female client tells the nurse she does not want her adult children to know she is dying. Later that day when the adult children visit, they tell the nurse that they know their mother is dying but will not talk about this in front of her. The nurse mentions in the intershift report that this family's situation is one that can be characterized in which way? a. Closed awareness b. Mutual concern c. Mutual pretense d. Open awareness

a. Unconscious thoughts of suicide are present.

A young adult client frequently engages in high-risk behaviors, including driving at high speed, drinking excessively, and engaging in high-risk sexual behaviors. The nurse assessing this client should recognize that there is a high probability that which of the following is occurring? a. Unconscious thoughts of suicide are present. b. Unhealthy grieving is occurring. c. Arrested maturation is impairing judgment. d. Antisocial personality traits are causing disregard for life.

c. Possible child abuse

An 18-month-old client is scheduled for a minor surgical procedure. The client has numerous large bruises of different stages over the back and buttocks. The mother states that the child must have fallen down while playing alone but cannot provide specific information. How should the nurse evaluate this situation? a. Indications of tissue fragility b. Normal findings in an 18-month-old c. Possible child abuse d. Immature parenting

d. Chronic low self-esteem

An adult survivor of child abuse states, "Why couldn't I make him stop the abuse? If I were a stronger person, I might have been able to make him stop. Maybe it was my fault he abused me." Based on this data, which would be the most appropriate priority nursing concern? a. Social isolation b. Anxiety c. Inability of family to cope d. Chronic low self-esteem

a. Determine if the client is experiencing abuse or neglect.

An older adult has been admitted to the hospital for dehydration. The client is poorly dressed, has body odor, appears unkempt, and has numerous unexplained bruises. He also states that he has not been receiving his medications from his caregiver. What should be the nurse's priority initial action? a. Determine if the client is experiencing abuse or neglect. b. Explore methods of rehydration attempted at home. c. Contact the appropriate elderly protective services agency. d. Inquire about medications the client is taking.

a. Find solutions to an immediate and overwhelming problem

An unlicensed mental health worker asks the nurse to explain how crisis intervention works. The nurse responds that crisis intervention helps the client to do which of the following? a. Find solutions to an immediate and overwhelming problem b. Become aware of personal limitations that led to the crisis state c. Uncover unconscious processes and early life experiences d. Use new ways of coping with an unexpected major problem

a. Grief related to perceived inability to achieve developmental milestones

During a counseling session, a 21-year-old client with schizophrenia verbalizes feelings of sadness and anger about being unable to keep a job or continue attending college. What priority concern should the nurse address? a. Grief related to perceived inability to achieve developmental milestones b. Inability to cope related to feelings of hopelessness and anger c. Ineffective grieving process related to unrealistic expectations of abilities and lack of achievement d. Anxiety related to fear of unknown and fear of failure

c. The client will be allowed to use own cosmetics and grooming products.

During an assessment interview the client says, "I can't stop worrying about my makeup. I can't go anywhere nor do anything unless my makeup is fresh and perfect. I wash my face and put on fresh makeup at least once and sometimes twice an hour." The nurse's priority should be to adjust the client's plan of care so that which of the following will happen? a. The client will be required to spend daytime hours out of own room. b. The client will be given advance notice of approaching time for all group therapy sessions. c. The client will be allowed to use own cosmetics and grooming products. d. The client will be asked to keep a diary of feelings experienced if unable to groom self at will.

c. Severe

During client assessment, the nurse finds that the client is trembling and restless, blood pressure and pulse are elevated, heart is pounding. The client reports nausea, headache, and dizziness. His behavior is highly disorganized. The nurse should conclude that this client is experiencing which level of anxiety? a. Panic b. Mild c. Severe d. Moderate

d. Impaired cognition

Nursing assessment indicates that a client is experiencing a panic attack shortly after arriving alone to the emergency department. The client states he is afraid, is unable to understand directions from the nurse, and manifests disorganized thinking. Which should be the priority nursing concern? a. Lack of social support systems b. Flight risk c. Impaired communication d. Impaired cognition

b. Uncertainty about how to communicate personal needs

The client in a crisis state is having difficulty asking for help from significant others. The nurse explains to caregivers that it is important to model asking for help because, in addition to being anxious and overwhelmed, clients in crisis often exhibit which trait? a. Hesitancy to depend on others for assistance with problem resolution b. Uncertainty about how to communicate personal needs c. Guardedness and protectiveness about talking about anxiety and other feelings d. Resistance to verbal suggestions about how problems can be approached

d. Remain calm and serene. e. Use short simple sentences.

The client is experiencing a panic attack. Which actions by the nurse would be appropriate at this time? Select all that apply. a. Speak loudly and firmly. b. Restrict the client's physical activity. c. Teach cognitive restructuring skills. d. Remain calm and serene. e. Use short simple sentences.

a. The realistic nature of the crisis event b. The precipitating event (precipitant) c. Current feelings e. The client's appraisal of the event

The client is in a crisis state secondary to a flood destroying her home, which resulted in immediate homelessness. During the assessment interview, what should the nurse assist the client to identify? Select all that apply. a. The realistic nature of the crisis event b. The precipitating event (precipitant) c. Current feelings d. Exploration of alternative solutions to the problem e. The client's appraisal of the event

a. "I should stop taking this medication abruptly." b. "I don't need to go to therapy since the medication is working." d. "I will probably have to take this medication for the rest of my life."

The client is taking alprazolam to reduce anxiety related symptoms. Which statements indicate that the nurse should provide more teaching to the client? Select all that apply. a. "I should stop taking this medication abruptly." b. "I don't need to go to therapy since the medication is working." c. "I might not be able to drive while I am taking this medication." d. "I will probably have to take this medication for the rest of my life." e. "This medication will help alleviate some symptoms of my anxiety."

d. The client cannot process the event with the usual support network.

The client presents in a crisis center saying, "They didn't want me. After 20 years, my boss just walks in and says I no longer have a job." The client's therapist is ill and unavailable, and the client's immediate family is away and unreachable by phone. What will the nurse interpret as the most significant reason the client is in crisis? a. The client is not making sufficient attempts to cope with the event. b. The client is misperceiving the event. c. The client feels confusion and shock about the event. d. The client cannot process the event with the usual support network.

d. "I enjoy being back at work with my friends."

The nurse has been caring for a client with posttraumatic stress disorder (PTSD). Which statement by the client would indicate the most improvement? a. "I can't relax. I stay alert all the time." b. "I am responsible for what happened to me." c. "I like to stay awake all night." d. "I enjoy being back at work with my friends."

d. Moderate

The nurse has established the following long term goal for a client who has chronic anxiety: "The client will learn new ways of coping with anxiety." For which level of anxiety is this goal most appropriate? a. Mild b. Panic c. Severe d. Moderate

c. "The client will experience anxiety without feeling overwhelmed." d. "The client will work through problems without being devastated."

The nurse has taught an anxious client a relaxation technique. The nurse should evaluate the effect of the instruction on which client goals? Select all that apply. a. "The client will suppress anxious feelings." b. "The client will confront the source of the anxiety." c. "The client will experience anxiety without feeling overwhelmed." d. "The client will work through problems without being devastated." e. "The client will keep a journal of times anxiety is experienced."

b. "Are you comfortable discussing the abuse?"

The nurse is caring for a client who is being treated for migraine headaches. Upon physical exam the nurse assesses old scars on the client's arms and legs. The client confides childhood memories of sexual abuse by the father. What should be the nurse's immediate response? a. "How did you get the scars?" b. "Are you comfortable discussing the abuse?" c. "Tell me more about your migraines." d. "How old were you when the abuse stopped?"

a. She is correct that her children may be at risk for abuse. b. She is correct that her pets may be at risk for injury or death from her spouse. d. It is probable that her husband may try to sabotage her career goals.

The nurse is caring for a female client who comes to the emergency department with bruises on the face, a cracked tooth and back pain. She voices concern about the safety of her pets and children, and her ability to enroll in her college as she plans. The nurse replies by explaining which of the following? Select all that apply. a. She is correct that her children may be at risk for abuse. b. She is correct that her pets may be at risk for injury or death from her spouse. c. Her children are safe; there is no correlation between spousal violence and injury to children. d. It is probable that her husband may try to sabotage her career goals. e. Her pets are safe; there is no correlation between interpersonal violence and injury to pets.

b. Possible emotional abuse or neglect

The nurse is conducting a home visit. The nurse observes a five-year-old child wearing a diaper while sucking his thumb, rocking, and banging his head. The child made adequate verbal responses to the nurse's verbal greeting. What should the nurse suspect this behavior to represent? a. Pervasive developmental disorder b. Possible emotional abuse or neglect c. An indication of autistic disorder d. Intellectual developmental delay

b. Domestic violence cuts across all socioeconomic lines. c. Domestic violence cuts across all educational levels.

The nurse is conducting an in-service program on risk factors for victims of domestic violence. The nurse should include which information about risk factors during the session? Select all that apply. a. Gay/lesbian persons are at not risk. b. Domestic violence cuts across all socioeconomic lines. c. Domestic violence cuts across all educational levels. d. A high school dropout is at higher risk then a high school graduate. e. Persons of lower economic status are at higher risk than those of higher economic status.

c. Reassure the victim that the sexual assault was not her fault.

The nurse is counseling an extremely distressed female victim immediately after a sexual assault. What should be the nurse's most important initial intervention? a. Collect a serum specimen for pregnancy testing. b. Ask the client to provide a sample of pubic hair for the evidence kit. c. Reassure the victim that the sexual assault was not her fault. d. Teach the client about the risk for sexually transmitted infections.

d. Recognizing crying as an age-appropriate way to communicate

The nurse is evaluating a family in which an 18-month-old son has been abused by both parents. During the initial nursing interview, the parents stated that they spank the toddler because he "cries and cries and never tells us what is wrong." The parents are adolescents who are still in high school. The nurse determines that what parental outcome would indicate progress? a. Less use of spanking for discipline b. Joint attendance at parenting classes c. Holding unreasonable expectations for their child d. Recognizing crying as an age-appropriate way to communicate

a. "One reason she may have stayed is because of traumatic bonding." b. "Maybe she has come to think violence is acceptable." d. "One reason she may have stayed is the fear of losing her children." e. "Women may stay in violent relationships due to fear, helplessness, guilt, or shame."

The nurse is working on a neurologic unit. A client with three young children is unconscious and has sustained a traumatic brain injury from a severe beating. Another staff nurse on the unit states, "She was stupid for staying in the relationship; she deserved it." What is the most appropriate responses by the nurse? Select all that apply. a. "One reason she may have stayed is because of traumatic bonding." b. "Maybe she has come to think violence is acceptable." c. "Yes, she has a lot of family and friends whom she could have gone to." d. "One reason she may have stayed is the fear of losing her children." e. "Women may stay in violent relationships due to fear, helplessness, guilt, or shame."

d. Remain focused on the client's perceptions.

The nurse is working with a client in crisis who recently had an abortion. The client is crying and tells the nurse she regrets it, because she loved her unborn child. In addition to establishing trust with the client, which nursing action should take highest priority? a. Determine the relationship of early life experiences and the crisis state. b. Obtain a complete assessment of the client's past obstetric history. c. Develop an action plan for the client that helps relieve her sadness. d. Remain focused on the client's perceptions.

c. Ensuring the client is safe

The nurse is working with a client who is severely anxious. The nurse should identify which nursing concern as having highest priority for the client at this time? a. Trying to get the patient to socialize b. Addressing maladaptive coping c. Ensuring the client is safe d. Discussing the denial aspects of the problem

d. severe

The nurse observes a patient who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands, and trembling. He seems confused. The nurse identifies this anxiety as: a. panic b. moderate c. mild d. severe

c. The client will display the ability to cope with mild anxiety.

The nurse should formulate which goal as most appropriate for a client who has been diagnosed as having generalized anxiety disorder (GAD)? a. The client will verbalize a sense of control over ritualistic behaviors. b. The client will describe dissociative experiences. c. The client will display the ability to cope with mild anxiety. d. The client will relive the traumatic event.

a. What treatment should be provided or omitted if the client becomes incapacitated

When questioned by a client about what an advance directive or living will is, the nurse should respond that this document indicates which of the following? a. What treatment should be provided or omitted if the client becomes incapacitated b. Details about preferred caregivers for end-of-life care c. Which practitioners should be allowed to provide end-of-life care d. Which family members are to be responsible for making end-of-life decisions

b. Encourage the client to make a list of problems from most urgent to least urgent.

When working with a depressed client who has suicidal ideation, the nurse anticipates that the client may be overwhelmed by personal problems. With this in mind, the nurse should take which action to best assist the client to cope more effectively? a. Support the client's decision to put off problem solving until outpatient therapy has begun. b. Encourage the client to make a list of problems from most urgent to least urgent. c. Take a directive approach and advise the client on how to prioritize personal problems. d. Encourage the client to work on problems only in group therapy.

a. Anticipatory grieving

Which nursing care measure should the nurse identify as a teaching priority for a family and child newly diagnosed with leukemia? a. Anticipatory grieving b. Comfort measures c. Bereavement counseling d. Distraction activities

d. getting fired from job

Which of the following is an example of a patient experiencing a situational crisis? a. tornado wipes out of town b. going away to college for first time c. being taken hostage and then released d. getting fired from job